Care Assessment Needs - Organizational Excellence
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Care Assessment Needs

Coordinating care throughout the VA is a longstanding goal of the Department, as Veterans receive better-quality, more-efficient care when all systems work together. Coordinated care can also result in reducing unplanned or unnecessary care, which leads to a more positive experience for Veteran patients and their loved ones. VA encouraged providers from home-based primary care, case-management, specialty services, telehealth and palliative care to work together with the hope that it would increase providers’ ability to accurately predict high-risk patients. By working together, providers recognized the need for a systematic method to identify high-risk Veterans.

In 2013, VA created the Care Assessment Needs (CAN) Score to help Patient Aligned Care Teams (PACT) identify Veteran patients who are statistically at the highest risk of hospitalization or mortality. The score looks at factors such as demographics, coexisting conditions, vital signs, utilization of services, pharmacy visits and lab results to determine if the patient is high risk. Specifically, the score shows the probability of readmission to a hospital or mortality within a specific amount of time, such as 90 days or one year. The score also compares the Veteran with other individuals and ranks them in a percentile from zero (lowest risk) to 99 (highest risk).

A second edition of the CAN score was released in 2015, and it was further improved in 2017. The most-recent edition aimed to improve the general accuracy and dependability of the data, which improved the efficiency of the entire process by nearly 25 percent. The CAN score helps VA providers better understand their patients’ needs and allows them to confirm if their high-risk patients are on the appropriate treatments or receiving an adequate amount of care, therefore improving overall care for Veterans.

Impact on Veterans

The CAN score improves care of Veteran patients and their loved ones by improving and encouraging care coordination throughout the VA system. VA providers also have a systematic way to determine if their patients are receiving the right treatments, and can link patients to services, resources or therapies if needed.